35 year old male with pain in lower chest region




 "This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current based inputs.

Case

35 year old Male who is a Biochemistry teacher by occupation came with a chief complaints of

 • Pain in the  left lower chest region since 19 days 

• Vomitings since 14 days

History of presenting illness

▪Patient was apparently asymptomatic 7 years back then he had fall from bike due to fainting then he was diagnosed as diabetic at local hospital since the he was on medication( metformin- 500 mg) regularly till 2019 and was on regular checkup monthly with dietary practices

▪ He used to drink alcohol occasionally  since 2008.He started drinking alcohol heavily since 2019 January due to personal problems and was not on regular medications for diabetes then after 2 weeks he had vomiting and abdominal pain for which he was hospitalized and diagnosed acute pancreatitis and his blood sugar levels was very high for which he was given insulin  from then he was on GLYCOMET -MV1  (metformin and voglibose)

▪ Then he stopped drinking alcohol for 2 months during this period of 2 months he was alright

▪Then he again started drinking and was not regular on diabetic medication and then he had recurrent episodes of abdominal pain following heavy drinking for which he stopped taking alcohol for 2 days and then he resumed again

▪3 years ago patient had corn on plantar aspect of great toe, patient himself used to cut the thickened part with a blade, which one year ago turned into an ulcer, for which he underwent debridement 1 year ago and 4 months back. He does his own dressing by using spirit to clean and the area and then puts iodine and cotton on it, every alternate day but it was not healed and some times he had pain which was radiating upto ankle joint

▪He quit his job 2 years ago and is only staying at home since then, but occasionally teaches as a guest lecturer.

  ▪︎2 years ago he attempted suicide by consuming OP poison and was admitted and treated outside for it. 

▪ He had accident 19 days back when he was drunk and then he developed pain and swelling but he neglected it because he was on alcohol totally and did not take any food .Pain  gradually increased which was throbbing type and non radiating and increased on taking deep breath and on lying on left lateral position relieved on medication

▪ After 4 days he had single episode of vomiting at night which was blood stained  so he stopped taking alcohol and next day  about 10 to 15 episodes and which was non bilious  initially and bilious there after and non projectile and contents as food particles  for which he came to our hospital and he was not taken any medication for diabetes  since 10days
  .He reports intolerance on drinking water as well, feels nauseous as soon as he consumes water. 
   He was not taken any medication for diabetes  since 10days.
 He was given Zofer for vomitings and IV fluids were given and his sugar levels were 500-600mg/ dl he was put on Insulin for first 2 days he was normal then he developed itching all over the body but they continued itching for next 2 days then he had severe itching all over the body ( avil was given) so insulin was stopped and was given oral medication glimiperide 4mg morning , metformin 500 mg morning and glimiperide - 3 mg , metformin 500 mg night. He want' s go to de - addiction centre but his sugar levels are not controlled he was sent back 


Past history

▪ Known case of diabetes since 8 years 

▪No history of hypertension, asthma, epilepsy, CAD

Family history

 Not significant

Personal history 

 Diet- mixed

Appetite- normal ( does not take food when he consumes alcohol )

Sleep- inadequate( when he does not take alcohol)

Bowel and bladder movements- regular

Habits- consumes alcohol from 2009 occasionally but from 2019 consumed daily ,  smokes while drinking about 5 to 6 each time

General examination

 Patient was conscious , coherent, cooperative well oriented  to time , place person 

Pallor- mild

icterus- absent

cyanosis- absent

clubbing- absent

Lymphadenopathy - absent

Edema- absent



VITALS-

Temp: 98°F

PR: 78bpm

RR: 18 cpm

BP: 120/80 mm hg

SpO2: 98% on RA

 GRBS- 


 • 15/3/2022- 500 to 600 mg/dl

•16/3/2022

 2AM (16/3/22): 101mg/dl 

6AM (16/3/22): 97 mg/dl

8 AM ( 16/3/22): 144 mg/dl

•18/03/2021

 8am- 323mg/dl

10am- 259 mg/ dl

1pm- 251mg/ dl

3pm- 245 mg /dl 

7pm -245 mg/ dl

•22/3/2022

8am -310 mg /dl

10am - 277mg/ dl

•24/3/2022

4 am- 171 mg/dl

7am  -341 mg/dl

10am- 250 mg/dl

11am -166 mg/dl

3pm- 341 mg/dl 

•25/ 3 /2022

4am -171g/dl

7am -341 mg/dl

1pm- 209 mg/dl

7pm -166 mg/dl

10 pm- 209mg/dl

•26/ 3/2022

7am - 166 mg/dl

10am- 304 mg/dl

3pm-  296mg/dl

7 pm -201mg/dl

10pm- 269mg/dl

•27/ 3/ 2022

6 am- 271 mg/dl

8am- 169 mg/dl

10am-- 306 mg/dl

2pm- 117 mg/dl


Systemic examination

▪CVS-- 
Inspection- 

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse or pulsations can be appreciated in sixth intercostal space 2cms lateral to mid clavicular line

Palpation-

Apical impulse is felt in the sixth intercostal space, 2 cm away from the midclavicular line

Percussion- 

Right and left borders of the heart are percussed 

Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard



RESPIRATORY SYSTEM- 

Inspection-

Chest is bilaterally symmetrical

The trachea is positioned centrally

Apical impulse is not appreciated

Chest moves normally with respiration

No dilated veins, scars or sinuses are seen

Increased respiratory rate noted

Palpation- 

Trachea is felt in the midline 

Chest moves equally on both sides 

Apical impulse is felt in the sixth intercostal space 

Tactile vocal fremitus- appreciated 

Percussion-

The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.

They are all resonant.

Auscultation-

Normal vesicular breath sounds are heard

Bilateral basal crepts noted in infra axillary area and infra mammary area


P/A-

    Distended abdomen 

  Soft, non tender






▪CNS-

 -Patient is conscious

-Speech -normal
-No signs of meningeal irritation

-SENSORY EXAMINATION,- touch, pain , vibration present

-No muscle wasting seen

-Tone of muscles is normal


▪REFLEXES:-

• Deep tendon reflexes

                        Right.                  Left

  Knee jerk.      +2                       +2

  Ankle reflex  +2                       +2    

  Biceps.            +2.                      +2      

  Triceps.          +2                       +2

  Supinator.     +2.                      +2    

 
•Power:

Biceps.            5/5.                  5/5

Triceps.          5/5.                  5/5

Extensors of knee
                       5/5.                    5/5        
  Flexors of knee
                     5/5.                       5/5

Exetnsors of hip
                      5/5.                      5/5

Flexors of hip
                     5/5.                       5/5

•Gait -normal
▪Coordination

- Finger nose test-able to perform

- knee heel test- able to operform

- Romberg sign- negative


Investigation

 ▪ 15/3/2022

 S. Lipase: 48 IU/L

S. Amylase: 74 IU/L

Urine for ketone bodies: negative 

•LFT: 

TB: 1.08

DB: 0.24

AST: 18

ALT: 10

Alk P: 242

TP: 7.3

Alb: 4

A/G: 1.23

•ABG:
 
USG ABDOMEN


• Chest x ray AP view


• ECG


Serum creatinine: 1.0
Serum urea: 15

•Hemogram: 
Hb: 10.5

TLC: 5,400

N:65

L: 28

PLT: 2.30


 •Electrolytes

Na: 138

K: 4.1

Cl: 99


▪ 17/03/2022

Hba1c- 8.1


Provisional diagnosis

 •Uncontrolled sugars with diabetic left foot(great toe)ulcer 
•RTA with left 7th rib fracture , alcohol dependency


Treatment
Tab - Glimeperide 4mg morning
Tab - Glimiperide 3mg night 
Tab - Metformin 500mg bd
Tab - Pan 40 mg
Tab - Dolo 650 mg
Tab-Ultracet 1/2 tab QID

https://aitharaveena.blogspot.com/2022/03/35-year-old-male-with-pain-in-loqer.html?m=1

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